Nokea
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement?
- A. Withhold next scheduled dose of treatment.
- B. Maintain the prescribed fluid restriction.
- C. Assess for increasing fluid volume overload.
- D. Increase neurologic checks to every 2 hours.
Correct Answer: B
Rationale: Maintaining fluid restriction supports gradual correction of hyponatremia in SIADH, preventing further sodium dilution.
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The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Uneven hair distribution.
- B. Lower leg edema.
- C. Bronze pigmentation.
- D. Bounding peripheral pulse.
Correct Answer: A
Rationale: Uneven hair distribution results from reduced blood flow impairing hair follicle nutrition, a sign of peripheral arterial disease.
History and Physical
Nurses’ notes
Laboratory Results
Flow Sheet
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Administer antiemetic
- B. Monitor for adverse reaction to antibiotics
- C. Increase IV fluids to 150 mL/hr
- D. Initiate airborne isolation
- E. Repeat CD4+ T-cell count STAT
Correct Answer: A,B,C
Rationale: Antiemetics , antibiotic monitoring , and increased fluids address emesis, treatment safety, and hydration in Pneumocystis pneumonia.
Imaging Studies
Day 1, 1100
X-ray of right foot erosion of first metatarsal joint and preservation of joint space consistent with gout
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks
Select the 3 dietary choices that are not part of the recommended diet gout.
- A. Shrimp
- B. Sardines
- C. Quinoa
- D. Oranges
- E. Oatmeal
- F. Spinach
- G. Liver
Correct Answer: A,B,G
Rationale: Shrimp , sardines , and liver are high in purines, which increase uric acid levels and should be avoided in gout management.
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
- A. Inflammation
- B. Discoloration
- C. Erythema Cyanosis
- D. Swelling
- E. Bruising
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.